Future directions of CAM research in pediatric oncology.

Children with cancer are using complementary and alternative medicine (CAM) to relieve symptoms, reduce side effects of treatment, and cope with the emotional aspects of having a life-threatening illness. Parental decisions about using CAM should be based on studies of efficacy and safety. Unfortunately, little evidence of efficacy is available for the majority of CAM therapies. This article discusses the methodological challenges to conducting CAM research in children and the evidence needed to support integrative medicine in pediatric oncology.     

Complementary and alternative medicine in pediatric oncology

OBJECTIVES: To summarize research in complementary and alternative medicine (CAM) therapies used for children with cancer and to explore issues and directions for measuring outcomes of CAM therapies in children. DATA SOURCES: Scientific and research articles, internet for active research studies. CONCLUSION: CAM is increasingly used as adjunctive cancer therapies in pediatrics. Mind-body and touch therapies have the greatest evidencefor effectiveness in reducing psychological and physical stressors. Supplements and herbal therapies receive the greatest interest, however, and more research is needed to determine efficacy in improving symptoms or outcomes in children with cancer. IMPLICATIONS FOR NURSING PRACTICE: Mind-body and touch therapies can be used by nurses to reduce symptoms and anxiety in children. Potential risks and benefits should be determined for therapies that have no evidence.     

Complementary and alternative medicines for use in supportive care in pediatric cancer

Introduction Complementary and alternative medical practices (CAM) are being used by increasing numbers of children with cancer. Discussion Recent surveys report CAM use prevalence rates of 24–90% in children with cancer. Interest in supporting children through the side effects or stress of conventional treatment has been described as one of the major motivating factors for the use of CAM therapies. Research is difficult secondary to the complexity of the therapies and lack of standardization. However, several research studies investigating CAM therapies for supportive care in children with cancer are ongoing. Information on several studies in progress through the Children’s Oncology Group and other institutions will be reviewed. Conclusion The progress made in the development of these studies demonstrates that CAM therapies can be investigated for their supportive care roles in the therapy of children with cancer. Presented as an invited lecture at the MASCC/ISOO 18th International Symposium of Supportive Care in Cancer in Toronto, Canada, June 2006.     

A systematic review of nonpharmacologic adjunctive therapies for symptom management in children with cancer.

Symptom management in pediatric oncology remains a problem. Despite remarkable pharmacologic and surgical advances, children continue to report symptoms as the most troublesome aspect of cancer treatment. However, there are additional therapies that are not considered standard symptom management, such as acupuncture and guided imagery. These nonpharmacologic adjunctive therapies are a potential source of assistance for children with unrelenting pain, nausea, or other unpleasant symptoms due to cancer treatment. This article summarizes research studies that have examined nonpharmacologic therapies for symptom management in pediatric oncology.     

Using a mixed methods research design to investigate complementary alternative medicine (CAM) use among women with breast cancer in Ireland

AimTo investigate complementary and alternative medicine (CAM) use among women with breast cancer in Ireland using a mixed methods modified sequential explanatory design.MethodsSemi-structured interviews were conducted with oncology professionals (n = 20) and CAM practitioners (n = 20) and this was followed by a survey of 406 women with breast cancer using the ‘Use of Complementary and Alternative Therapies Survey’ questionnaire (UCATS) (Lengacher et al., 2003). Follow up interviews were subsequently undertaken with a subset of this survey sample (n = 31).ResultsOver half of those surveyed (55.7%, n = 226) used some form of CAM since diagnosis. The most frequently used therapies were massage, herbal supplements (including herbs with oestrogenic properties), antioxidants, relaxation, counselling, health supplements, reflexology, reiki and support groups. Dietary interventions were used primarily to reduce symptoms and/or side effects while reduction of psychological stress was the primary reason for use of stress-reducing therapies. Most respondents reported that the CAM therapies they had used were helpful. The qualitative data elaborated on and provided clarification of the survey results.ConclusionsSimilar to international studies, CAM is popular among women with breast cancer in Ireland. As such, the challenge for Irish oncology professionals is to identify low risk CAM therapies that are likely to benefit patients while educating patients and themselves on therapies which may be of concern. This study clearly illustrates the benefits of using a mixed methods approach to enhance our understanding of a complex clinical issue and thus we recommend that this method should be the method of choice when planning health services research.     

Complementary and alternative medicine use in pediatric oncology patients in eastern Turkey

The use of complementary and alternative medicines (CAM) among children with cancer is becoming increasingly popular. Therefore, it is important to gain insight into the prevalence and factors related to the use of CAM. This study presents findings from a study of parents of 88 children with cancer who were receiving or had received conventional therapy for treatment of childhood cancer at a pediatric oncology unit in eastern Turkey. The findings indicated that 48.9% of the respondents reported the use of 1 or more CAM therapies. The most commonly used modality was herbal products such as herbal tea and herbal meal, mostly stinging nettle (Urtica dioica). The findings of this study indicate that CAM users were children who were an average of 3 years older than nonuser children and that CAM use was more prevalent among the children who had been diagnosed with cancer for a longer time than nonusers. There were no significant difference between users and nonusers regarding sociodemographic characteristics (such as age education level, economic status), hopelessness score of parents, gender of child, and treatment status. Healthcare providers should remain informed about the benefits and adverse effects of complementary and alternative therapies to discuss treatment options with patients and their families and to monitor treatment efficacy.     

Critique 1: Complementary and Alternative Medicine in Pediatric Oncology

Research on CAM therapies in pediatric cancer patients is in its infancy and more research is clearly warranted given the high use of CAM therapies and the largely unknown benefits, toxicities, and interactions. To obtain adequate sample sizes, multi-site research is necessary. Multi-site research in this area is challenging, but the challenges are not insurmountable. Careful design and attention to the unique issues of conducting multi-site CAM research in pediatric cancer patients would be a worthwhile undertaking with the potential for valuable, clinically significant outcomes.     

HIV: effectiveness of complementary and alternative medicine

Outcome studies examining the efficacy of CAM among people living with HIV-AIDS are often conducted among small sample sizes with very little follow-up data or time points. Generalizability of many of the study findings is further limited by participant attrition. It is difficult to conduct clinical studies on chronically ill patients without participants dropping out, typically because the study demands coupled with their illness become too burdensome. Several studies have been conducted that include control groups, double-blind designs, and randomization. These scientifically sound studies have demonstrated promising results that strongly indicate a need for further research with larger samples in a prospective research design so that safety and efficacy can be determined over time. Many of the studies with small sample sizes reported trends, but did not find statistical significance. Increasing sample sizes in future studies is necessary to evaluate the scientific merit of these trends. Moreover, researchers need to evaluate the clinical and statistical significance in CAM use. The psychologic benefits of taking CAM should not be underestimated. For the purposes of this article, the authors did not include psychologic outcomes; however, there is evidence suggesting that decreasing depression can decrease HIV-related somatic complaints [69]. Studies need also to examine the effectiveness of CAM on psychologic outcomes and physical outcomes. This article and the authors' own research (Gore-Felton C et al, unpublished data) have revealed a high prevalence of alternative supplement use in conjunction with HIV medication, indicating an urgent need to understand the health benefits and the health risks of alternative supplements among patients with HIV and AIDS. Patients and physicians need more empirically based research to examine the toxicities, interactions, and health benefits of CAM. Many patients do not report the use of CAM to their physicians and very few physicians record treatments in the clinical record [70]. This will likely change as CAM becomes more widely recognized as a legitimate medical intervention; however, controlled outcome studies among large, diverse samples of people living with HIV-AIDS are needed. Health care providers need to assess the use of herbal and alternative therapy practices by their patients. Some patients may not be aware that they are taking a supplement or plant-based herb. Furthermore, some patients may believe that they are using something innocuous and even healthy simply because it came from a health food store. Understanding the contraindications of alternative therapies is necessary to prevent deleterious outcomes and to facilitate the safe and efficacious use of CAM in the management of HIV disease and related symptoms. As the epidemic in the United States continues to rise among women and minority populations, clinical research trials must include ethnically diverse patient populations that are gender balanced. Current available studies indicate that many CAM interventions may improve the quality of life of people living with HIV-AIDS; however, further studies using longitudinal, controlled designs are needed to accurately assess the safety of such interventions.     

Use of complementary and alternative medicine therapies to control symptoms in women living with lung cancer

Complementary and alternative medicine (CAM) use by cancer patients, especially women, is increasing. However, CAM use among patients with lung cancer, who have been reported to have the highest symptom burden, is poorly documented. This study describes types and frequencies of specific CAM therapies used by women with lung cancer to manage symptoms, and examines differences in demographic and clinical characteristics between CAM users and non-CAM users. Participants included 189 women with non-small cell lung cancer and > or =1 of 8 symptoms. Six CAM therapies, used to control symptoms, were assessed, including herbs, tea, acupuncture, massage, meditation, and prayer. Forty-four percent (84 women) used CAM therapies, including prayer (34.9%), meditation (11.6%), tea (11.6%), herbs (9.0%), massage (6.9%), and acupuncture (2.6%). Complementary and alternative medicine use was greatest for difficulty breathing and pain (54.8% each), with prayer the most commonly used CAM for all symptoms. Significant differences (P < .05) were found for age (t = 2.24), symptom frequency (t = -3.02), and geographic location (chi = 7.51). Women who were younger, experienced more symptoms, and lived on the West Coast or South (vs Northeast) were more likely to use CAM. We found that CAM use is variable by symptom and may be an indicator of symptom burden. Our results provide important initial data regarding CAM use for managing symptoms by women with lung cancer.     

Pediatric patients with sickle cell disease: use of complementary and alternative therapies

OBJECTIVE: Despite clinical advances, sickle cell disease (SCD) remains a difficult, chronic medical condition for many children and youth. Additional treatment strategies, including complementary and alternative medicine (CAM) therapies, would be welcome to enhance the clinical care of SCD patients. This study's objective was to identify CAM therapies that are currently used by families for children with SCD, and to investigate SCD families' interest in CAM. PATIENTS AND METHODS: Fifty-seven (57) parents of pediatric SCD patients participated in this cross-sectional telephone survey in early 2000. A SCD Severity Scale was developed by combining the general health assessment and four measures of SCD severity (Cronbach's alpha = 0.81). RESULTS: Fifty-four percent (54%) of the sample used CAM therapies for the SCD children. Forty-two percent (42%) used bioenergetic therapies (prayer, spiritual and energy healing), 28% used lifestyle/mind?body CAM (relaxation techniques, exercise, imagery, and diet), 12% used biochemical therapies (herbal medicines, megavitamins, and folk remedies), and 5% used biomechanical therapy (massage). CAM use for the SCD children was positively associated with the child's age, SCD Severity Scale score, respondent education, and respondent CAM use. The use of relaxation techniques was associated with greater SCD severity. Most respondents (83%) felt that CAM can be helpful. CONCLUSIONS: The use of CAM therapies is common for children with SCD. Prayer, relaxation techniques, and spiritual healing were the most commonly reported CAM therapies. Because clinical studies have shown the benefit of spiritual and relaxation practices for SCD and this study shows that these CAM therapies are being used commonly by SCD families, future research should focus on spiritual and relaxation practices for children with SCD.     

'Thinking outside the box': complementary and alternative therapies use in paediatric oncology patients.

The aim of this study was to determine the prevalence of complementary and alternative medicine (CAM) use among children with cancer who had received or were receiving treatment at a large hospital in the UK, including the identification of the most commonly used therapies and parental motives for doing so. Using a cross-sectional survey design, questionnaires were sent to parents of paediatric patients diagnosed with cancer. Of the 49 respondents, 32.7% reported using some type of CAM. The most commonly used therapies included multivitamins, aromatherapy massage, diets and music as therapy. Most children had used more than one therapy. Many of the factors that motivated parents to use CAM were related to helping or supporting their child's medical treatment. The main benefits identified from using CAM included increased confidence, pain relief and relaxation. The longer the time since diagnosis the more children tended to use CAM. The reasons for parents not using CAM included the child doing well and therefore not seeing the need for CAM use; not being aware of CAM; CAM not being offered and lack of information available. Parents identified a need for more information to be available both at ward level and for information about CAM to be discussed by medical staff, particularly at the start of treatment. The results indicate that CAM is frequently used by children and young people with cancer and that their use plays a substantial role in helping children through their conventional cancer treatment.     

Omega-3 fatty acids for the treatment of cancer cachexia: issues in designing clinical trials of dietary supplements

Complementary and alternative medicine (CAM) is increasingly popular, despite the limited evidence of the efficacy and safety of some forms of CAM. Cancer patients often turn to CAM therapies for the relief of treatment- induced side-effects and comorbidities. Cancer-associated weight loss commonly results in decreased functional status, life expectancy, and quality of life. Despite the high morbidity and mortality associated with cancer cachexia, mainstream treatments do not sustain weight. Although nutritional supplements are commonly used, many of these have not been tested in clinical trials. The issues faced in dietary supplement research differ from those in pharmaceutical drug trials. These include problems with standardization, contamination, and compliance documentation. A double-blind, randomized, placebo-controlled trial is proposed to evaluate the efficacy and safety of fish oil supplementation for the treatment of cachexia in pancreatic cancer patients. The primary outcome measure will be lean body mass; secondary outcomes include functional status and quality of life. The methodology of the clinical trial is reviewed here and the unique problems faced by investigators in designing studies of dietary supplements are discussed.     

Use of complimentary and alternative medicine by breast cancer patients: prevalence, patterns and communication with physicians

This study examined the use of complementary and alternative medicine (CAM) therapies by breast cancer patients and the communication of their CAM use to their physicians relative to lymphedema symptoms and other factors. Breast cancer patients ( N = 148) in the State of Vermont were interviewed 2-3 years after their primary surgery using computer-aided telephone interviewing methods. Questionnaire items included demographic information, treatment, CAM use, lymphedema symptoms, and other measures. A large proportion (72.3%) reported using at least one CAM treatment after surgery. The most frequently used treatments were vitamins and nonfood supplements (72.3%), with herbal treatments, meditation, and traditional massage each being reported by about one-fifth of the women. Age, education, adjuvant chemotherapy, and extremity swelling were associated with use of more CAM treatments in a regression model. A large proportion (73.8%) of CAM users reported their CAM use to their physicians. Correlations between patients' income, adjuvant radiation therapy, and adjuvant tamoxifen use with communication of CAM use to their physicians were sought in a logistic regression model. CAM use is high among breast cancer patients in Vermont, and the number of CAM therapies used is related to demographic factors, adjuvant treatment, and lymphedema symptoms. Communication of CAM use to physicians appears to be multifaceted.     

Complementary and alternative therapies to manage HIV-related symptoms.

Persons with HIV infection report substantial use of complementary and alternative medical (CAM) therapies for symptom management. Anecdotal reports from patients indicate that CAM approaches are helpful; however, there is limited scientific information on the safety and efficacy of these therapies in the HIV population. The purpose of this review is to critically appraise the scientific evidence for selected CAM therapies that are used by HIV-infected persons to manage three common symptoms: nutritional alterations, pain, and depression.     

Complementary and alternative medicine research initiatives in the Children's Oncology Group and the role of the pediatric oncology nurse.

Complementary and alternative medicine (CAM) has emerged as a new area of investigation in cancer research and treatment. CAM modalities are widely used, but little is known about their efficacy. The Children's Oncology Group has made a major commitment to CAM research in childhood and adolescent cancer, beginning with studies of CAM in the area of supportive care. Pediatric oncology nurses, as implementing clinicians and collaborating researchers, are critical to the success of these studies.     

Attitudes toward complementary and alternative medicine amongst oncology professionals in Brazil

Complementary and alternative medicines (CAM) are popular amongst cancer patients in the Brazilian context, however little is known about oncology health professionals’ attitudes toward the role of CAM and their perspectives on the potential for integration into oncological care. In this study, drawing on a series of interviews with oncology professionals (i.e. doctors, nurses, nutritionists, pharmacologists and psychologists), we provide insight into their views on the rise, validity, and role of CAM in cancer care. The results reveal two key dynamics in relation to CAM in cancer care in Brazil. First, that doctors, nurses and other allied professionals hold considerably different views on the value and place of CAM, and in turn ascribe it varying levels of legitimacy potentially limiting integration. Second, that while some health professionals may articulate a degree of support for CAM, this is limited by perceptions of CAM as lacking efficacy and intruding on their respective jurisdictional claims. Further research is needed in the Brazilian context to explore patient and professional perspectives on experiences on CAM in cancer care, including how oncology professionals’ varying positions on CAM may influence what patients are prepared to use, or discuss, in the context of cancer care.     

Integrating complementary medicine and supportive care: patients' perspectives toward complementary medicine and spirituality

Abstract Objectives: The association of spirituality and complementary and alternative medicine (CAM) in oncology is unfolding as a research theme that may have practical implications in supportive care. The purpose of this study was to explore patients' perspectives regarding CAM and spirituality in order to address their needs in an integrative oncology program. Methods: A 27-item questionnaire was developed that was administered by research assistants to a convenience sample of patients attending a community-based oncology service in northern Israel. Results: Of the 509 respondents, 302 (67.4%) were undergoing active oncological treatment and 146 (32.6%) were doing follow-up surveillance. Current and/or previous year CAM use for oncology treatment was reported by 244 of 495 respondents (49%). A logistic regression model indicated that CAM use was associated with younger age, Jewish religion, and higher cancer-related spiritual quest [EXP(B)=2.102, 95% confidence interval for EXP(B) 1.236-3.575, p=0.006]. Compared with patients with lower spiritual quest, CAM users with higher spiritual quest expressed more expectations of CAM counseling in the following themes: improving daily functioning and coping with disease, lessening chemotherapy side-effects, and supporting the patient and family emotionally and spiritually. In addition, they expected their social worker to be more involved in building the CAM treatment plan compared to patients with average spiritual quest (35.3% versus 16.3%, p=0.038). Conclusions: Higher degree of spiritual quest is associated with increased CAM use, and higher expectations from CAM providers and social workers in the context of CAM integration within cancer care.     

Women's perceptions and beliefs about the use of complementary and alternative medicines during menopause

INTRODUCTION: Studies of menopausal women are providing increasing evidence of the reasons for complementary and alternative medications (CAM) use during menopause, the types of CAM used and the prevalence of use; however, further insight into the experiences of women using CAM during menopause is required. The aim of this study was to put CAM use during menopause into context by identifying and describing the factors that influence menopausal women in their decision to use CAM. METHODS: Menopausal women participated in focus groups and telephone interviews and the following information were collected: symptoms experienced during menopause; therapies (other than hormones) used to cope with menopause, and the perceived benefits of these therapies, and how the women found out about these therapies. The data collected were analysed using thematic analysis. RESULTS: Fifteen women participated in the study; 13 in the focus groups and two in telephone interviews. The women reported using a diverse range of therapies, supplements and activities. Empowerment was a central theme throughout the study. The level of support from the women's general practitioners was reported to be a major influence in their decision to take CAM. The availability of information about CAM and individual determinants, such as symptoms and perceptions of menopause, were also identified as significant influences. CONCLUSION: The women in this study expressed a desire to have control over their symptoms and the way in which their menopause was treated. This study has highlighted a need for more information and education about menopause and, in particular, the range, safety and efficacy of CAM use during menopause. The study also shows there is a need for strong participatory relationships between women and their health professionals.     

Doctor–patient communication and cancer patients’ choice of alternative therapies as supplement or alternative to conventional care

Scand J Caring Sci; 2013; 27; 70–76 Doctor–patient communication and cancer patients’ choice of alternative therapies as supplement or alternative to conventional care Cancer patients’ use of complementary and alternative medicine (CAM) is widespread, despite the fact that clinical studies validating the efficacy of CAM remain sparse in the Nordic countries. The purpose of this study was to explore possible connections between cancer patients’ communication experiences with doctors and the decision to use CAM as either supplement or alternative to conventional treatment (CT). The Regional Committee for Medical and Health Research Ethics and the Norwegian Data Inspectorate approved the study. From a group of 52 cancer patients with self‐reported positive experiences from use of CAM, 13 were selected for qualitative interviews. Six used CAM as supplement, and seven as alternative to CT, periodically or permanently. Communication experiences with 46 doctors were described. The analysis revealed three connections between doctor–patient communication and patients’ treatment decisions: (i) negative communication experiences because of the use of CAM; (ii) negative communication experiences resulted in the decision to use CAM, and in some cases to decline CT; and (iii) positive communication experiences led to the decision to use CAM as supplement, not alternative to CT. The patients, including the decliners of CT, wanted to discuss treatment decisions in well‐functioning interpersonal processes with supportive doctors. In doctors’ practices and education of doctors, a greater awareness of potential positive and negative outcomes of doctor–patient communication that concern CAM issues could be of importance. More research is needed to safeguard CAM users’ treatment decisions and their relationship to conventional health care.